Jean-Marie Bruzzese

School-based asthma programs

Asthma is prevalent in school-age children and contributes to school absenteeism and limitation of activity. There is a sizable literature on school-based interventions for asthma that attempt to identify children with asthma and improve outcomes. The purpose of this review is to describe and discuss limitations of screening tools and school-based asthma interventions. Identification of children with asthma may be appropriate in schools located in districts with a high prevalence of children experiencing significant morbidity and a high prevalence of undiagnosed asthma, provided there is access to high-quality asthma care. We review strategies for improving access to care, for teaching self-management skills in schools, and for improving school personnel management skills. Although studies indicate that school-based programs have the potential to improve outcomes, competing priorities in the educational system present challenges to their implementation and emphasize the need for practical, targeted, and cost-effective strategies.

Effects of a school-based intervention for urban adolescents with asthma. A controlled trial.

RATIONALE Asthma prevalence and morbidity are especially elevated in adolescents, yet few interventions target this population. OBJECTIVES To test the efficacy of Asthma Self-Management for Adolescents (ASMA), a school-based intervention for adolescents and medical providers. METHODS Three hundred forty-five primarily Latino/a (46%) and African American (31%) high school students (mean age = 15.1 yr; 70% female) reporting an asthma diagnosis, symptoms of moderate to severe persistent asthma, and asthma medication use in the last 12 months were randomized to ASMA, an 8-week school-based intervention, or a wait-list control group. They were followed for 12 months. MEASUREMENTS AND MAIN RESULTS Students completed bimonthly assessments. Baseline, 6-month, and 12-month assessments were comprehensive; the others assessed interim health outcomes and urgent health care use. Primary outcomes were asthma self-management, symptom frequency, and quality of life (QOL); secondary outcomes were asthma medical management, school absences, days with activity limitations, and urgent health care use. Relative to control subjects, ASMA students reported significantly: more confidence to manage their asthma; taking more steps to prevent symptoms; greater use of controller medication and written treatment plans; fewer night awakenings, days with activity limitation, and school absences due to asthma; improved QOL; and fewer acute care visits, emergency department visits, and hospitalizations. In contrast, steps to manage asthma episodes, daytime symptom frequency, and school-reported absences did not differentiate the two groups. Most results were sustained over the 12 months. CONCLUSIONS ASMA is efficacious in improving asthma self-management and reducing asthma morbidity and urgent health care use in low-income urban minority adolescents.

Asthma knowledge and asthma management behavior in urban elementary school teachers.

Background. Although schools are an important setting for asthma care in youth, teachers’ asthma knowledge and symptom management is poor. This study investigated the knowledge, prevention and management behaviors, and communication regarding asthma of teachers of low-income, ethnic minority students. It was hypothesized that relative to colleagues whose students did not have active asthma (i.e., did not have symptoms during the day), teachers of students with active asthma would have better asthma knowledge and that more would take asthma prevention steps and communicate with parents and school nurses. Methods. Drawing from 25 elementary schools in New York City, 320 pre-Kindergarten through 5th grade classroom teachers with at least one student with asthma completed measures assessing their asthma knowledge, steps taken to manage asthma, communication with the school nurse or parents, information they received about asthma, and whether or not they had at least one student in their class experience asthma symptoms. t test and chi-square were used to test hypotheses. Results. Asthma knowledge varied among teachers. Most could identify potential triggers, yet few knew that medication taken prior to exercise could prevent symptoms and that students with asthma need not avoid exercise. Communication between teachers and school nurses and between teachers and parents was lacking. Relative to colleagues whose students did not have active asthma, teachers whose students had active asthma had better asthma knowledge, more took steps to prevent students from having asthma symptoms, communicated with parents, and more initiated communication with the nurse. Conclusions. Teachers’ knowledge about asthma and asthma management is limited, especially among those whose students did not have active asthma. Teachers respond reactively to students who have symptoms in class by increasing prevention steps and communications with parents and the school nurse. A more proactive approach to managing asthma in schools is warranted.

Illness‐specific anxiety: Implications for functioning and utilization of medical services in adolescents with inflammatory bowel disease

PURPOSE. Adolescents with inflammatory bowel disease (IBD) may be at heightened risk for developing anxiety and depression. This cross-sectional pilot study examined the relationship between anxiety and depression and health-related behaviors. METHODS. Thirty-six adolescents with diagnosed IBD, ages 12-17, and their parents were recruited from two pediatric gastroenterology medical centers. RESULTS. Clinical levels of anxiety (22%) and depressive symptoms (30%) were reported by patients. Regression analyses revealed that IBD-specific anxiety was significantly associated with greater utilization of medical services and worsened psychosocial functioning. PRACTICE IMPLICATIONS. Results provide preliminary support that IBD-specific anxiety may play an important role in disease management, yet concerns are rarely systematically assessed by health professionals.

Asthma and social anxiety in adolescents.

OBJECTIVE To examine the relationship between self-reported social anxiety and asthma in a non-clinical sample of adolescents. STUDY DESIGN High school students (n = 765) completed the Social Anxiety Scale for Adolescents (SAS-A), the Social Phobia and Anxiety Inventory for Children (SPAI-C), and questions on asthma diagnosis, asthma symptoms, and asthma-related limitations and medical care. Relationships were examined between social anxiety symptoms and asthma, including history of diagnosis, diagnosis plus current symptoms, and severity. RESULTS Compared with students without an asthma diagnosis and no symptoms, students with a diagnosis and current symptoms reported heightened social anxiety symptoms related to fear of negative evaluations and generalized discomfort in social settings as measured by the SAS-A. Additionally, a greater proportion of students with an asthma diagnosis and current symptoms were in the clinical range of social anxiety on the SAS-A. Differences on the SAS-A by history of asthma diagnosis and by severity were not supported. No differences were found on the SPAI-C for history of asthma diagnosis, diagnosis plus current symptoms or severity. CONCLUSIONS Students with current asthma symptoms were more likely to report social anxiety, perhaps related to concerns about exhibiting symptoms or taking medication in front of peers. These findings may suggest advantages for medical providers to identify and treat social anxiety in patients with asthma.

Asthma Self-Management is Sub-Optimal in Urban Hispanic and African American/Black Early Adolescents with Uncontrolled Persistent Asthma

Introduction. Youth as young as 11 are given responsibility to manage their asthma. Yet, little is known regarding early adolescents’ asthma self-management behaviors. This study characterizes urban early adolescents’ asthma self-management behaviors and perceived responsibility to manage asthma, exploring demographic differences and examining the relationship between asthma responsibility and disease management. Methods. About 317 Hispanic and African American/Black early adolescents (mean age = 12.71) with persistent, uncontrolled asthma reported prevention and symptom management steps, and responsibility for asthma care. We used Poisson, cumulative logistic, logistic, and linear mixed-effects regression models to assess the relationships among demographic predictors, prevention and management behaviors, and responsibility for asthma care. Results. Fifty percent took 7–9 prevention steps; few saw physicians when asymptomatic or took daily medication. When symptomatic, 92% used medication to treat symptoms and 56% sought medical attention. Controlling for asthma responsibility, fewer older youth reported observing how they feel when asthma is likely to start, observing symptom changes, or asking for help. More boys reported taking medication daily or upon trigger exposure. Controlling for age, gender, and race/ethnicity, those reporting more asthma responsibility were less likely to report taking management steps, seeking preventive care, asking for help, or going to a doctor/hospital for their asthma. Conclusions. Early adolescents’ asthma self-management is suboptimal. With increasing age, they are less observant regarding their asthma and less likely to seek help. Although they perceive themselves to have greater responsibility for managing their asthma, early adolescents do less to care for their asthma, suggesting they are being given responsibility for asthma care prematurely.

Integrating illness concerns into cognitive behavioral therapy for children and adolescents with inflammatory bowel disease and co-occurring anxiety.

PURPOSE To examine the feasibility and preliminary benefits of an integrative cognitive behavioral therapy (CBT) with adolescents with inflammatory bowel disease and anxiety. DESIGN AND METHODS Nine adolescents participated in a CBT program at their gastroenterologists office. Structured diagnostic interviews, self-report measures of anxiety and pain, and physician-rated disease severity were collected pretreatment and post-treatment. RESULTS Postintervention, 88% of adolescents were treatment responders, and 50% no longer met criteria for their principal anxiety disorder. Decreases were demonstrated in anxiety, pain, and disease severity. PRACTICE IMPLICATIONS Anxiety screening and a mental health referral to professionals familiar with medical management issues is important.

Effective Methods to Improve Recruitment and Retention in School-Based Substance Use Prevention Studies

BACKGROUND Poor recruitment and high attrition may invalidate results of research studies. This paper describes successful recruitment and retention strategies in a school-based substance use prevention trial and explores factors associated with intervention attendance and retention. METHODS A total of 384 parent-child dyads from 15 schools in the New York Metropolitan area participated in a control trial, testing the efficacy of parent-training to prevent youth substance use. Assessments were completed immediately post-intervention and 6-, 12-, and 24-month postintervention. Logistic regression analyses were used to determine which familial and study characteristics predicted attendance in the intervention and retention by parents and youth. RESULTS 84% of intervention parents attended 4 of the 5 workshops; 83% of control parents attended their single workshop. Intervention attendance was predicted by parent job status, but this was not significant after controlling for other family factors. Retention rates ranged from 87% to 91% over the 2 years. No family characteristics predicted retention, but time since baseline and attendance at treatment workshops and the control workshop did. For children, age at baseline and ethnicity predicted retention, but this did not remain significant in the adjusted model. CONCLUSION Intervention attendance was high and retention rates far exceeded the minimum standard of 70% retention in behavioral studies. Recruitment and retention strategies were effective for different family constellations. Efforts to maximize participation in both treatment and control interventions are critical to retention in longitudinal trials.

Fitbit Flex: an unreliable device for longitudinal sleep measures in a non-clinical population

Dear Editor, Clinicians and researchers are increasingly interested in employing tracking devices to measure activity and sleep, both of which are calculated via algorithms that use accelerometer data [1]. While polysomnography (PSG) is viewed as the gold standard for assessing sleep, it is costly, time-intensive, and intrusive. Actigraphy is often preferred in situations for which PSG is not indicated, such as naturalistic conditions or for prolonged observations—days to weeks. However, actigraphs are relatively expensive as well, making them unsuitable to monitor large samples. As such, activity-tracking devices have been proposed as an alternative. Several recent reports, including one by Montgomery-Downs [2] published in this journal, suggest that consumer-level devices might offer a valid and reliable alternative, as they are easy to use and relatively low in cost [2–4]. We are writing this letter to report our disappointing experience with Fitbit Flex to measure sleep in a non-clinical sample of college students. We utilized the Fitbit Flex to measure sleep parameters longitudinally in a sample of college students enrolled in an IRB-approved pilot study of their sleep. One hundred and seven college students consented to monitor their sleep by wearing a Fitbit Flex for 1 week at three time points—baseline (September 2014), post-intervention (November 2014), and 3month follow-up (February 2015). Prior to baseline data collection, trained research staff taught the college students how to use the Fitbit Flex using a standardized protocol. The students also watched a video tutorial that explained how to operate the device. Additionally, we provided students the link to view the online video tutorial should they need a reminder on how to operate the device. Despite these efforts, the devices failed to capture a significant amount of sleep data at baseline (see Fig. 1): only about 14 % of the Fitbit Flexes recorded sleep six or seven nights and nearly 35 % failed to record any nights of sleep. Hypothesizing that the lack of data collected was due to user error, we retrained the students using a modified approach. After showing them how to use the Fitbit, we then asked participants to demonstrate how to track their sleep, including how to determine via the device’s light and vibration patterns to which mode the device was set (i.e., if the device was in the sleep mode or not). Students received the Fitbit Flex only after they demonstrated correct use. We subsequently found even less data were collected than previously, with nearly 70 % failing to capture any sleep data (see Fig. 1) or activity data. Of note, the lack of both sleep and activity data indicates a device failure rather than participants’ misuse. Prior to each distribution, the devices were fully charged and synced, and they appeared to function appropriately as signaled by light and vibration patterns. Due to the poor data obtained at the first two time points, we canceled the third objective sleep assessment. We contacted the Fitbit company for technical support, but found them to be generally unresponsive and ultimately not able to rectify the situation. While prior studies comparing Fitbits to actigraphs have indicated that consumer-level devices might be a feasible alternative to actigraphs, especially in non-clinical populations, most of these investigations focused on performance over a limited time period of 1 or 2 days. We are aware of only one other study that tested the performance reliability of a Fitbit * Jess P. Shatkin jess.shatkin@nyumc.org

My Child is Diagnosed With Asthma, Now What? Motivating Parents to Help Their Children Control Asthma

Pediatric asthma is often undiagnosed, and therefore untreated. It negatively impacts children’s functioning, including school attendance and performance, as well as quality of life. Schoolwide screening for asthma is becoming increasingly common, making identification of possible asthma particularly relevant for school nurses. Nurses may need to help parents cope with the new diagnosis, and teach them skills to manage the illness. The aim of this article is to present a three-phase model of how parents cope with a newly diagnosed pediatric chronic illness. Using asthma as an example, we describe these phases (Emotional Crisis, Facing Reality, and Reclaiming Life), illustrate how parents progress through the phases, and discuss situations associated with possible regression. Next, we offer strategies framed around a theory of asthma self-management to assist school nurses and other medical providers to motivate parents to develop successful disease management skills.